1. Pre-clinic information for patients
Google search “Bristol thoracic surgery”

2. Videolinked pre-operative assessment in thoracic surgery: an update
Alistair Johnstone, Eveline Internullo, Gianluca Casali, Claire Dowse, Doug West
University Hospitals Bristol NHS Trust

3. Why? principles Increasingly fewer, larger units
Patient demand for care close to home
To streamline our care pathways to improve referral to treatment times
To improve the patients experience of care
Reduce waste
Maintain standardisation
Why? principles

4. ~900 thoracic patients per year, 400 lung resections, 278 for primary lung cancer, 80% thoracoscopic ( )
100% reviewed by anaesthetists pre operatively
Standardised pre-operative assessment and optimisation programme
Purpose built £2.4m pre operative department opened 2015
Routine DOSA
Lung cancer LOS 5 days
About us

5. Where do our patients come from?
254 Patients with “non Bristol” postcodes
Nov – April 2014
Source: UH Bristol Data / Medway

6. How long does it take patients to get to the BRI?
N=157 patients
Unselected, April14

7. “35 mins to get to Bristol then another 45 minutes driving round trying to find somewhere to park”
“waited ages for the hospital bus”
“does not include time waiting for transport”
“had to leave really early with transport”
“Approx 1 hour then 40 mins finding a parking space near enough to walk to hospital”
It’s not always easy!
N=157 patients
Unselected, April14

8. Round trip mileage to BRI
Gloucester Royal 80 miles
Yeovil 86 miles
Bath RUH 25 miles
Musgrove Park 94 miles
Weston 46 miles
Round trip mileage to BRI

9. Video Pre-Op Assessment

10. Traditional Pathway 2-5 Days 2-3 Days 11 - 22 Days 7-14 Days
MDT decision to refer to surgery
Wednesday Day 0
2-5 Days
Traditional Pathway
Referral letter
Typed Thursday Day 1
Arrive Friday Day 2 (best case scenario)
2-3 Days
Days
Triage/Booking clinic appointment
Monday Day 5
7-14 Days
Clinic appointment at BRI
Surgical clinic + Preop clinic
Wednesday Day 7 (Best case scenario)
Friday Day 9 (Most likely scenario)
Tuesday Day 13 (Occasionally)
Wednesday Day 14 (Occasionally)
? High risk
Complex case review meeting
Second line tests + review
Surgery

11. new pathway 1 Days 7 Days 6 Days MDT decision to refer to surgery
Wednesday Day 0
new pathway
1 Days
Fast Referral/Triage
Booking clinic appointment
7 Days
6 Days
Clinic appointment at remote site
Surgical clinic + VIDEO Preop clinic
Wednesday Day 7 (Routinely)
Second line tests + high risk MDT
Surgery

12. ONE STOP CLINIC IN THE PERIPHERY
SOUTHMEAD MODEL
WHO DOES WHAT BY WHEN DOCUMENT
MDT decision to refer to surgery
Output
Effective handover of information to the surgical team
Achieved with one of the two followin options
Fast referral
Referral Letter
WEEK 0
Day 0: Wednesday
Clinic Appointment VIDEO POAC VIDEO CNS
Output
Patient ready for surgery
Achieved with
Completed Pathway (Surgeon + POAC nurse)
Signed Consent
Education (Surgical CNS + POAC + Surgeon)
ECG, Bloods
WEEK 1
Day 7: Wednesday
Surgery
WEEK 1 + X DAYS
Surgery
Advanced tests Specialist assessments
WEEK 1 + X DAYS

13. MDT decision to refer to surgery
Output
Effective handover of information to the surgical team
Achieved with one of the two followin options
Fast referral
Referral Letter
WEEK 0
Day 0: Wednesday
FAST REFERRAL
Who Surgeon and Resp Physician does what fill the fast referral form
by when by the end of the MDT
Who Surgeon
does what brings the fast referral form to the BRI by when by Day 0 + 1
Who Secretary
does what Create T number by when by Day 0 + 1
does what fills in the ICE form by when by Day 0 + 1
Who CNS
does what ensures that patient is booked in clinic by when by Day 0 + 1
does what ensures that BRI knows about booking in Southmead To avoid double booking
by when by Day 0 + 1
does what organises Bloods, ECG, other missing tests by when by Day 0 + 1

14. Reducing delays: North Bristol data
TIME REFERRAL TO CLINIC (DAYS)
REMOTE + VIDEO
CONTROL
MEDIAN (RANGE)
6 (0-15)
10 (0-30)
MEAN
5.4
11.6
TIME REFERRAL TO READY FOR SURGERY (DAYS)
10 (2-43)
24 (2-87)
12.9
25.8
TIME CLINIC TO READY (DAYS)
5 (1-30)
13 (0-78)
7.5
14.9
TIME REFERRAL TO OPERATION (DAYS)
12 (7-61)
43 (16-119)
22.8
44.6
CLINIC TO OPERATION (DAYS)
6 (4-61)
29 (6-119)
17.5
Reducing delays: North Bristol data
Referral
Clinic
POAC
Ready
Operation

15. Median times: NBT

16. What do our patients think?
I think it is a very good idea to do the video interviews as it saves extra visits to the hospital
Overall the service is great…..
I was very pleased to be part of the video pre op assessment.
Everything worked well and I saved a great deal of time. I hope that it becomes a regular routine
What do our patients think?
I enjoyed taking part…. found it very friendly….it saved a long journey to the BRI….
When I actually went for my op I felt I knew everybody already…
I thought it was very good…it saved me time going to the BRI and time trying to find parking.
It was very straight forward and the nurse and anaesthetist were very nice.

17. Why have we been successful?
Multi disciplinary working, lead by clinicians who could identify problems and implement solutions
Stepwise changes, decided by not imposed on clinicians
Reducing administrative delays whilst continuing to deliver high quality, patient focused care
Integrating existing technology into care pathways to improve patient experience
Why have we been successful?
Cancer Specialist Nurses
Pre Op Nurses
Lung Cancer MDT Lead
Administrators
Surgeons
Anaesthetists
IT departments
Clinical Operations Managers
Outpatient Nurses

18. Starting: lessons so far
Two sites
Southmead
Gloucester Royal 2016
Easier second time!
Led by CNS and nursing teams on both sites
POAC slots owned by local team
Technology issues surmountable
Weekly clinic essential
Fast referral proforma helpful
Patients like it!
Starting: lessons so far

19. Challenges and the future
Advanced testing – CPEX
Trial recruitment
Consent documentation
Staffing in POAC
Tariff reimbursement
Roll out to all weekly peripheral clinics
More optimisation in 2WW- smoking / COPD
Video trials consent
?video follow up
Recording discussions and sharing with patients
Challenges and the future